PassFinals
Vascular Surgery

Varicose Veins

Varicose veins are superficial veins made tortuous by venous reflux; symptoms, skin change, ulceration, bleeding or thrombosis determine referral, with duplex-guided intervention preferred over routine compression hosiery when treatment is suitable.

In a nutshell

Varicose veins are superficial venous dilatations caused by reflux and chronic venous hypertension. Symptomatic veins, skin change, thrombosis, ulceration or bleeding need vascular referral and duplex mapping; for confirmed truncal reflux, NICE recommends endothermal ablation, then foam sclerotherapy, then surgery if preceding options are unsuitable.

Classic presentation

Visible tortuous leg veins with aching, heaviness, itching or dependent swelling that worsens through the day and improves with elevation.

Key points

  • Venous valve failure causes reflux and pooling; chronic venous hypertension can produce pigmentation, eczema, lipodermatosclerosis and ulcers.
  • Refer symptomatic or recurrent varicose veins, venous skin change, superficial vein thrombosis with suspected incompetence, healed or active venous ulcer and bleeding; bleeding is immediate.
  • Duplex ultrasound confirms the diagnosis, maps truncal reflux and plans intervention; do not use a fixed reflux-duration threshold as a substitute for the vascular assessment.
  • NICE treatment order is endothermal ablation, then ultrasound-guided foam sclerotherapy, then surgery when the preceding option is unsuitable.
  • Do not offer compression hosiery as routine treatment when intervention is suitable; assess arterial supply before compression for a venous ulcer.
  • Acute unilateral swelling or a tender superficial vein needs assessment for DVT and thrombosis extent, not automatic attribution to chronic varicosities.

First-line investigation

Standing clinical examination followed by vascular-service venous duplex ultrasound; assess arterial supply before ulcer compression and use the DVT pathway if acute thrombosis is suspected.

Management

Recognise complications

  • For bleeding, elevate the leg and apply firm direct pressure while arranging immediate vascular assessment; for acute swelling or thrombosis, use the DVT or vascular pathway.1,2,6

Refer and map reflux

  • Refer symptomatic or complicated disease to a vascular service and use duplex ultrasound to confirm the diagnosis, map truncal reflux and plan treatment.1

Treat suitable truncal reflux

  • Offer endothermal ablation first; if unsuitable offer ultrasound-guided foam sclerotherapy, and if that is also unsuitable offer surgery.1

Use compression safely

  • Reserve compression hosiery for when intervention is unsuitable or for selected pregnancy or ulcer pathways, and assess arterial supply before compression for a venous ulcer.1,4,3

Prevent recurrence and skin failure

  • Give activity, weight, elevation and skin-care advice, explain recurrence and possible repeat treatment, and ensure ulcer, thrombosis or recurrent-symptom follow-up through the appropriate vascular service.1,2

Exam traps

  • Bleeding from a varicose vein needs elevation, direct pressure and immediate vascular referral.
  • Compression hosiery is not first-line treatment for suitable interventional candidates under NICE CG168.
  • A venous ulcer is not treated with compression until arterial supply has been assessed.
  • Acute unilateral swelling should trigger the DVT pathway rather than reassurance about known varicose veins.
  • Superficial thrombophlebitis requires assessment of extent and proximity to the deep system; do not apply an automatic anticoagulation rule without current guidance and clinical review.
  • Interventional treatment is generally deferred during pregnancy except in exceptional circumstances; symptom-relieving compression may be considered.

Illustrations

Valve failure and reflux cascadeDiagram showing a competent valve versus an incompetent valve allowing retrograde flow that raises pressure in and dilates the vein below.PassFinals · original
Chronic venous insufficiency: haemosiderin pigmentation and lipodermatosclerosis of the lower legsLeg photograph showing dilated tortuous superficial veins alongside haemosiderin pigmentation and lipodermatosclerosis.James Heilman, MD, Wikimedia Commons · CC-BY-SA-4.0

Key sources

  1. NICE CG168: Varicose veins: diagnosis and management (Current NICE recommendations for information, vascular referral, duplex assessment, intervention sequence, compression, pregnancy and recurrent disease; last reviewed 4 February 2016 with no new evidence affecting recommendations identified.)
  2. NHS: Varicose veins (Current NHS information on symptoms, urgent advice for bleeding, referral indications, self-care and intervention options.)
  3. NHS: Venous leg ulcer (Current NHS information on venous-ulcer recognition, arterial assessment, compression therapy, wound care and infection advice.)
  4. NICE HTG677: Automated ankle brachial pressure index measurement devices to detect peripheral arterial disease in people with leg ulcers (NICE guidance explaining why arterial assessment, including ABPI as part of clinical assessment, helps determine whether compression is safe for venous leg ulcers.)
  5. NICE QS52: Peripheral arterial disease quality statement 1 (NICE quality standard supporting clinical assessment and ABPI measurement when peripheral arterial disease is possible or compression hosiery is being considered.)
  6. NICE NG158: Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (Current NICE pathway for suspected DVT or PE, including clinical probability assessment, ultrasound and anticoagulation decisions; last reviewed 1 May 2026.)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.